The nurse is educating a client about postpartum complications.
Which complication will be included for a primipara with a second-degree perineal laceration and repair?
Difficulty voiding spontaneously.
Delayed onset of milk production.
Maladaptive bonding with the newborn.
Posterior vaginal varicosities.
The Correct Answer is A
Choice A rationale
A second-degree perineal laceration involves the vaginal mucosa, perineal skin, and the perineal muscles, but not the anal sphincter. The proximity of the repair to the urethra and the potential for perineal edema and pain can inhibit the voiding reflex and cause urethral spasm, leading to temporary difficulty in spontaneously emptying the bladder post-delivery.
Choice B rationale
The onset of milk production (lactogenesis II) is primarily controlled by the rapid drop in progesterone levels following the expulsion of the placenta and subsequent increase in prolactin release. A second-degree perineal laceration and repair, which is a localized soft tissue injury, has no direct physiological impact on the endocrine cascade responsible for initiating lactation.
Choice C rationale
Maladaptive bonding is a complex psychological issue influenced by factors like maternal mental health, pain, fatigue, and social support. While a painful laceration can contribute to discomfort and stress, a second-degree tear itself is a physical injury and does not directly cause an abnormal bonding process, which is a behavioral and emotional phenomenon.
Choice D rationale
Posterior vaginal varicosities (enlarged veins) are caused by the increased venous pressure and blood volume associated with pregnancy, and potential pressure from the descending fetal head during labor. A second-degree perineal laceration and its repair are the result of the birthing process and do not cause pre-existing vascular conditions like varicosities.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Requesting oxytocin to strengthen the contractions may be necessary if the contractions are indeed hypotonic (weak). However, with a high resting uterine tone (20-25 mm Hg; normal 5-15 mm Hg) and frequent, short contractions, this pattern suggests hypertonic uterine dysfunction, and oxytocin is contraindicated as it would worsen the uterine hyperstimulation and compromise fetal oxygenation.
Choice B rationale
Advising the client to simply be patient is inappropriate for this dysfunctional labor pattern. This pattern, characterized by short, frequent contractions with high resting tone, is ineffective and often causes significant pain and maternal fatigue without adequate cervical change. Interventions are required to address the uterine dysfunction.
Choice C rationale
This labor pattern is consistent with hypertonic uterine dysfunction, where the baseline uterine tone is elevated, preventing proper uterine muscle relaxation and adequate placental perfusion. The best intervention is to promote uterine rest and relaxation, often achieved through therapeutic rest (e.g., pain medication, sedation, or a change in environment) to allow the dysfunctional pattern to resolve.
Choice D rationale
Ambulation and physical activity are typically encouraged for hypotonic (weak, infrequent) labor to stimulate stronger contractions. In cases of hypertonic uterine dysfunction, movement may increase pain and does not promote the necessary uterine rest and relaxation to normalize the contractile pattern, potentially leading to further maternal exhaustion and fetal compromise.
Correct Answer is B
Explanation
Choice A rationale
Amniotomy, the artificial rupture of membranes, is typically performed to induce or augment labor, especially if the membranes are intact and labor is progressing slowly. However, it carries risks such as cord prolapse, especially when the presenting part is floating (station -3 or higher), as noted, making this intervention inappropriate and potentially hazardous currently.
Choice B rationale
Early decelerations are a benign finding caused by transient fetal head compression during a contraction, mirroring the contraction shape. A floating presenting part (station greater than or equal to -3) signifies the fetal head has not yet entered the pelvic inlet, which is characteristic of the second stage of labor, or the active phase of the first stage of labor.
Choice C rationale
Early decelerations are considered a reassuring fetal heart rate pattern. Fetal distress is indicated by late or severe variable decelerations, persistent bradycardia, or absent variability, which are not present here. The FHR of 140 beats/min is within the normal range (110–160 beats/min), indicating adequate oxygenation.
Choice D rationale
A Cesarean birth is not immediately necessary. The findings—reassuring FHR pattern with early decelerations and a normal FHR of 140 beats/min—do not indicate fetal distress or an immediate maternal or fetal emergency that would necessitate urgent surgical intervention.
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